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When You Need A Referral Or Authorization For Services And Care:

If you need certain types of covered services or supplies, you must get approval in advance through your Primary Care Physician (PCP).

When your PCP thinks you need specialized treatment, he/she will either give you a referral to see a specialist (i.e. a cardiologist for patients with heart conditions) or certain other providers in our network, or will request a prior authorization (prior approval) from the Health Plan on your behalf.

It is very important to get a referral or prior authorization (approval in advance) from your PCP for the services and items listed below that require it. If you don’t have approval in advance for services or items that require a referral or prior authorization, you may have to pay for these services yourself.

You can get services such as those listed below without getting approval in advance from your PCP:

Routine women’s health care, which includes breast exams, screening mammograms (x-rays of the breast), Pap tests, and pelvic exams as long as you get them from a network provider.

Flu shots, Hepatitis B vaccinations, and pneumonia vaccinations as long as you get them from a network provider.

Emergency services from network providers or from out-of-network providers.

Urgently needed care from in-network providers or from out-of-network providers when network providers are temporarily unavailable or inaccessible, e.g., when you are temporarily outside of the plan’s service area.

Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area. If possible, please call Member Services before you leave the service area so we can help arrange for you to have maintenance dialysis while you are away.

Dermatology (up to 5 visits per year) must be from an in-network provider.

Behavioral Health Services - must be from an in-network provider.

Your PCP can issue a referral for the following listed services:

Participating specialists for office visit and treatments in the office that do not require prior authorization.

DME - only DME with a purchase price less than $500.00 or monthly rental price less than $38.50 per month. Excludes: all wheelchairs, hospital beds, CPAPs, BiPAPs, nerve and bone growth stimulation devices and oxygen, as well as TENS devices, wound care/wound vacuums and related supplies, repairs, miscellaneous codes and all Medicare non-covered items, all of which require prior authorization.

Your PCP will need to submit an authorization request prior to the following services being rendered (Prior Authorization is required):

Rehab – any outpatient hospital and any office therapy > than 10 visits.

Skilled Nursing Facility

Sterilizations

TMJ Joint treatment

Transplant

Wound Care (outpatient hospital only)

For more information on your coverage and when you need to get prior authorization or a referral, please call member services toll free at 1-866-245-5360 or TTY/TDD: 711. You may also refer to the Evidence of Coverage booklet you received in the mail for additional information.

Optimum HealthCare, Inc. is an HMO plan with a Medicare contract and a contract with the state Medicaid program. Enrollment in Optimum HealthCare, Inc.. depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, co-payments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Beneficiaries generally must use network pharmacies to access their prescription drug benefit. You must continue to pay your Medicare Part B premium. Medicare beneficiaries may also enroll in Optimum HealthCare through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next.

Depending on the services, a prior authorization or referral from your doctor may be required.

For Chronic Special Needs Plans (SNP): These plans are available to anyone with Medicare who has been diagnosed with Diabetes, Cardiovascular Disease, Chronic Heart Failure, or a qualified Chronic Lung Disorder, such as Chronic Obstructive Pulmonary Disease (COPD), Asthma, Chronic Bronchitis, Emphysema, Pulmonary Fibrosis, or Pulmonary Hypertension.

For Dual Special Needs Plans (DSNP): These plans are available to anyone who has both medical assistance from the state and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. The Part B premium is covered for full dual members of Special Needs Plans.